The Preserve

In the surveyor’s words

From the most serious findings on record at The Preserve, in the surveyor’s own words.

• Actual harm, isolatedF686May 31, 2023

  Based on record review, review of facility's policies and procedures, and interview the facility failed to ensure ongoing skin assessment and implementation of necessary preventive measures to prevent the development of pressure ulcers for 1 (Resident #1) of 4 sampled residents who developed a pressure ulcer at the facility. The findings included: The facility's policy and procedure for prevention and treatment of skin breakdown with a revised date of 7/2018 noted, It is the policy of Volunteers of America to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide the appropriate treatment modalities for wounds according to industry standards of care . […]

• No harm, potential for more than minimal, patternF690Feb 17, 2022

  Based on observations, record review and staff and resident interviews, the facility failed to ensure urinary catheters were maintained in a safe and sanitary manner for 3 (Resident #16, #32 and #37) of 3 residents sampled with indwelling urinary catheter. The findings included: 1. Review of the clinical record for Resident #32 revealed a quarterly MDS assessment dated [DATE] which noted the Resident required extensive physical assistance of two persons for bed mobility and toilet use. On 2/14/22 at 4:26 p.m., and 2/15/22 at 9:15 a.m., during observations Resident #32 was in bed and the urinary catheter drainage bag was resting on the floor. 2. […]

• No harm, potential for more than minimal, isolatedF585Jan 16, 2025

  Based on resident's family interview, staff interviews and record review the facility failed to ensure 1 (Resident #2) of 3 grievances reviewed had documentation of the steps taken to investigate the grievance, a summary of the pertinent findings or conclusion regarding the complainant's concern(s), a statement as to whether the complaint was confirmed or not confirmed, and the complainant was given a summary of the pertinent findings or conclusions regarding their concern(s). The findings included: The facility's Grievance/Concern Policy dated 3/2010 and last revised 5/1/23 stated: 1. Residents, resident representative or other individual on the resident's behalf, have the right to file a grievance with the facility at any time, without fear of discrimination or reprisal. 2. […]

• No harm, potential for more than minimal, isolatedF684Nov 16, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to accurately transcribe medication orders upon admission for 1 (Resident #118) of 6 residents reviewed for physicians orders. The findings included: Review of the facility policy titled Admission Orders dated 5/2022, revealed specification: 1) The facility will receive a medication list/reconciliation and required documentation prior to/or upon arrival of the resident to the facility. 2) A licensed nurse will review the medication reconciliation with the designated Primary Physician and /or Practitioner via telephone or verbally via face-to-face encounter. 3) The licensed nurse will document all correspondence and new orders in the Electronic Health Record (EHR). […]

• No harm, potential for more than minimal, isolatedF697Nov 16, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to accurately transcribe physician's admitting pain medication orders on admission, resulting in ineffective pain control for 1 (Resident #118) of 6 residents sampled for accuracy of physician's orders. The findings included: Review of a facility policy titled Admission Orders dated 5/2022 revealed specification: 1) The facility will receive a medication list/reconciliation and required documentation prior to/or upon arrival of the resident to the facility. 2) A licensed nurse will review the medication reconciliation with the designated Primary Physician and /or Practitioner via telephone or verbally via face-to-face encounter. […]